Edward Joyce

9 May 2018 · Coroner Philip Barlow · London Inner (South)

The coroner's concerns

1. delayed urgent referral for high temperature after burn
“The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital.”
2. lack of documented communication of critical temperature to parents
“[name redacted]'s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring [name redacted] back to hospital.”
3. inadequate awareness of post-burn sepsis risk among health professionals
“The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and the availability of 24 hour telephone advice from the burns unit.”

Stated action

“We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely.”